EP1330652A2 - Verfahren zur erkennung von eierstockkrebs mittels menschlichem kallikrein (hk6) - Google Patents

Verfahren zur erkennung von eierstockkrebs mittels menschlichem kallikrein (hk6)

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Publication number
EP1330652A2
EP1330652A2 EP20010982003 EP01982003A EP1330652A2 EP 1330652 A2 EP1330652 A2 EP 1330652A2 EP 20010982003 EP20010982003 EP 20010982003 EP 01982003 A EP01982003 A EP 01982003A EP 1330652 A2 EP1330652 A2 EP 1330652A2
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EP
European Patent Office
Prior art keywords
antibody
ovarian cancer
kallikrein
tumor
patients
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Granted
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EP20010982003
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English (en)
French (fr)
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EP1330652B1 (de
Inventor
Eleftherios P. Diamandis
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Mount Sinai Hospital Corp
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Mount Sinai Hospital Corp
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Classifications

    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
    • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
    • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
    • G01N33/53—Immunoassay; Biospecific binding assay; Materials therefor
    • G01N33/574—Immunoassay; Biospecific binding assay; Materials therefor for cancer
    • G01N33/57407—Specifically defined cancers
    • G01N33/57449—Specifically defined cancers of ovaries
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
    • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
    • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
    • G01N33/53—Immunoassay; Biospecific binding assay; Materials therefor
    • G01N33/574—Immunoassay; Biospecific binding assay; Materials therefor for cancer
    • G01N33/57484—Immunoassay; Biospecific binding assay; Materials therefor for cancer involving compounds serving as markers for tumor, cancer, neoplasia, e.g. cellular determinants, receptors, heat shock/stress proteins, A-protein, oligosaccharides, metabolites
    • G01N33/57488—Immunoassay; Biospecific binding assay; Materials therefor for cancer involving compounds serving as markers for tumor, cancer, neoplasia, e.g. cellular determinants, receptors, heat shock/stress proteins, A-protein, oligosaccharides, metabolites involving compounds identifable in body fluids
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N2333/00—Assays involving biological materials from specific organisms or of a specific nature
    • G01N2333/90—Enzymes; Proenzymes
    • G01N2333/914—Hydrolases (3)
    • G01N2333/948—Hydrolases (3) acting on peptide bonds (3.4)
    • G01N2333/95—Proteinases, i.e. endopeptidases (3.4.21-3.4.99)
    • G01N2333/964—Proteinases, i.e. endopeptidases (3.4.21-3.4.99) derived from animal tissue
    • G01N2333/96425—Proteinases, i.e. endopeptidases (3.4.21-3.4.99) derived from animal tissue from mammals
    • G01N2333/96427—Proteinases, i.e. endopeptidases (3.4.21-3.4.99) derived from animal tissue from mammals in general
    • G01N2333/9643—Proteinases, i.e. endopeptidases (3.4.21-3.4.99) derived from animal tissue from mammals in general with EC number
    • G01N2333/96433—Serine endopeptidases (3.4.21)
    • G01N2333/96441—Serine endopeptidases (3.4.21) with definite EC number
    • G01N2333/96455—Kallikrein (3.4.21.34; 3.4.21.35)

Definitions

  • the invention relates to diagnostic and prognostic methods for ovarian carcinoma.
  • pancreatic/renal kallikrein (KLK1, encoding for hKl protein), human glandular kallikrein 2 ( LK2, encoding for hK2 protein) and human kallikrein 3 (KLK3, encoding for hK3 protein or prostate-specific antigen, PSA).
  • PSA and hK2 are relatively prostatic-specific and they have already found important applications as biomarkers for the diagnosis and monitoring of prostate cancer (1-6).
  • This gene family now contains at least 14 genes which are all encoding for serine proteases, show significant homology at both the DNA and amino acid level and they are all localized at the chromosomal locus 19ql3.3-ql3.4, in tandem, without any intervention from other non-kallikrein genes. This area of investigation has recently been reviewed (1).
  • the KLK6 gene (encoding for human kallikrein 6, hK6) has been cloned independently by three groups of investigators and was previously given the names zyme (7), protease M (8) and neurosin (9). Recently, uniform nomenclature for all newly discovered and the traditional kallikrein genes has been established (10).
  • the KL 6 gene encodes for a trypsin-like serine protease of 244 amino acids in length, of which 16 amino acids constitute the signal peptide and 5 amino acids, the activation peptide.
  • the mature enzyme consists of 223 amino acids. It has been previously predicted that hK6 is a secreted protein (7-9,11).
  • PSA has proven to be the most valuable biomarker for prostate cancer and is currently used for diagnosis and monitoring of this disease (2-4).
  • Another potential prostatic biomarker, hK2 has also been recently introduced (5, 6).
  • kallikreins (1) none of them has been examined as a serological marker for any malignancy since no methods currentiy exist to measure the secreted proteins with high sensitivity and specificity.
  • Ovarian cancer is a serious disease which causes more deaths than any other cancer of the female reproductive system (13). Since survival could be dramatically improved if the disease is diagnosed early
  • hK6 A highly sensitive hK6 immunoassay for the measurement of hK6 in various biological fluids was developed (Example 1). Using this sensitive assay the hK6 concentration in serum was found to be significantly increased in a large proportion of patients with ovarian cancer. In particular, hK6 was found to be significantly increased in ovarian cancer patients when compared to normal non-cancer patients and patients with benign disease. Thus, hK6 constitutes a new biomarker for diagnosis and monitoring of ovarian cancer. hK6 may be used to diagnose and monitor late stage ovarian cancer, and it may be used as a biomarker before surgery or after relapse.
  • the present inventors also quantitated the amount of hK6 in extracts of ovarian tumors and determined that the amount of hK6 correlated with clinicopathological variables documented at the time of surgical excision and with progression free survival and overall survival. Increased hK6 levels were found to be predictive of more aggressive tumor behavior over time. hK6 positivity was found to be associated with about a 2-fold increase in the risk of both disease progression and of death.
  • hK6, and agents that bind to hK6 may be used to detect ovarian cancer and in particular they can be used in the diagnostic evaluation of ovarian cancer, and the identification of subjects with a predisposition to ovarian cancer.
  • the present invention relates to a method for diagnosing and monitoring ovarian cancer in a subject comprising measuring hK6 in a sample from the subject.
  • hK6 may be measured using a reagent that detects or binds to hK6 preferably antibodies specifically reactive with hK6 or a part thereof.
  • a method for detecting h 6 associated with ovarian cancer in a patient comprising:
  • the invention also relates to a method of screening a subject for ovarian cancer comprising: (a) obtaining a biological sample from a subject; (b) detecting the amount of hK6 in said sample; and (c) comparing said amount of hK6 detected to a predetermined standard, where detection of a level of hK6 greater than that of a standard indicates the presence of ovarian cancer, in particular late stage ovarian cancer.
  • detecting or “detect” include assaying, quantitating, imaging or otherwise establishing the presence or absence of the target hK6, subunits thereof, or combinations of reagent bound targets, and the like, or assaying for, imaging, ascertaining, establishing, or otherwise determining one or more factual characteristics of ovarian cancer, metastasis, stage, or similar conditions.
  • the term encompasses diagnostic, prognostic, and monitoring applications for hK6.
  • the invention relates to a method for detecting ovarian cancer in a subject by quantitating hK6 in a biological sample from the subject comprising (a) reacting the biological sample with an antibody specific for hK6 which is directly or indirectly labelled with a detectable substance; and (b) detecting the detectable substance.
  • the invention further relates to a method for diagnosing and monitoring ovarian carcinoma in a subject by quantitating hK6 in a sample from a subject comprising (a) reacting a biological sample from the subject with an antibody specific for hK6 which is directly or indirectly labelled with a detectable substance; (b) and detecting the detectable substance.
  • Embodiments of the methods of the invention involve (a) reacting a biological sample from a subject with an antibody specific for h 6 which is directly or indirectly labelled with an enzyme; (b) adding a substrate for the enzyme wherein the substrate is selected so that the substrate, or a reaction product of the enzyme and substrate forms fluorescent complexes; (c) quantitating hK6 in the sample by measuring fluorescence of the fluorescent complexes; and (d) comparing the quantitated levels to that of a standard.
  • the standard may correspond to levels obtained for other samples from the subject patient, or control subjects.
  • the quantitated levels are compared to levels quantitated for subjects without ovarian carcinoma wherein an increase in hK6 levels compared with the control subjects is indicative of ovarian carcinoma, in particular late stage ovarian carcinoma.
  • a preferred embodiment of the invention comprises the following steps
  • the standard may correspond to levels quantitated for samples from healthy control subjects, from subjects with benign disease, subjects with early stage disease, or from other samples of the subject. Increased levels of hK6 as compared to the standard may be indicative of ovarian cancer, in particular late stage ovarian cancer.
  • the invention also contemplates the methods described herein using multiple markers for ovarian cancer. Therefore, the invention contemplates a method for anaylzing a biological sample for the presence of hK6 and other markers that are specific indicators of ovarian cancer.
  • Other markers include markers to kallikreins such as human stratum corneum chymotryptic enzyme (HSCCE), kallikrein 4, kallikrein 5, kallikrein 8, kallikrein 9, kallikrein 10, kallikrein 11; CA125, CA15-3, CA19-9, OVX1, lysophosphatidic acid (LPA) and carcinoembryonic antigen (CEA).
  • HSCCE human stratum corneum chymotryptic enzyme
  • kallikrein 4 kallikrein 4
  • kallikrein 5 kallikrein 8
  • kallikrein 9 kallikrein 10
  • kallikrein 11 markers to kallikreins
  • the markers are two or more of hK6, hKlO, and CA 125.
  • the methods described herein may be modified by including reagents to detect the additional markers, or nucleic acids for the markers.
  • the invention also relates to a method for imaging a tumor associated with hK6 comprising
  • an in vivo method comprising administering to a subject an agent that has been constructed to target one or more kallikreins.
  • an in vivo method comprising administering to a mammal one or more agent that carries a label for imaging and binds to a kallikrein, preferably hK6, and then imaging the mammal.
  • an in vivo method for imaging ovarian cancer comprising:
  • the agent is an antibody which recognizes the kallikrein. In another embodiment of the invention the agent is a chemical entity which recognizes the kallikrein.
  • the agent carries a label to image the kallikreins.
  • labels useful for imaging are radiolabels, fluorescent labels (e.g fluorescein and rhodamine), nuclear magnetic resonance active labels, positron emitting isotopes detectable by a positron emission tomography (“PET”) scanner, chemiluminescers such as luciferin, and enzymatic markers such as peroxidase or phosphatase.
  • PET positron emission tomography
  • chemiluminescers such as luciferin
  • enzymatic markers such as peroxidase or phosphatase.
  • Short-range radiation emitters such as isotopes detectable by short-range detector probes can also be employed
  • a method for imaging ovarian cancer may further comprise injecting the patient with one or more of an agent that binds to human stratum corneum chymotryptic enzyme (HSCCE), kallikrein 4, kallikrein 5, kallikrein 8, kallikrein 9, kallikrein 10, kallikrein 11, CA125, CA15-3, CA19-9, OVX1, lysophosphatidic acid (LPA) or carcinoembryonic antigen (CEA), preferably CA 125.
  • HSCCE human stratum corneum chymotryptic enzyme
  • kallikrein 4 kallikrein 5, kallikrein 8, kallikrein 9, kallikrein 10, kallikrein 11, CA125, CA15-3, CA19-9, OVX1, lysophosphatidic acid (LPA) or carcinoembryonic antigen (CEA), preferably CA 125.
  • LSA lysophosphatidic acid
  • CEA carcinoembryonic antigen
  • Figure 1 is a calibration curve for a h 6 protein assay.
  • Figure 2 shows the results of high performance liquid chromatography separation of three biological fluids and analysis of all fractions with the developed hK6 immunoassay.
  • a single immunoreactive peak around fractions 38 - 42 was detected, corresponding to a molecular mass of- 30 kDa.
  • the column was calibrated with molecular weight standards (shown on top with arrows; masses are in kDa).
  • the milk sample was diluted 10 times before injection into the HPLC column.
  • Figure 3 is a graph showing the results of the analysis of various human tissue cytosolic extracts for hK6 protein
  • Figure 4 is a graph showing the frequency distribution of hK6 concentrations in the serum of 80 patients with ovarian carcinoma.
  • the level of 15 ⁇ g/L which was used as a cutoff in Table 1 is indicated by an arrow.
  • About 66% of ovarian cancer patients have serum hK6 concentration higher than this cutoff value.
  • Figure 5 is a graph showing the correlation between hK6 and CA125 concentration in 96 serum samples from ovarian cancer patients.
  • Figure 6 are graphs showing the analysis of hK6 and CA125 in serial serum samples from patients with ovarian cancer. These data suggest that hK6 may have value for patient monitoring.
  • Figure 7A is a graph showing the distribution of hK6 in normal, to benign, to cancer patients.
  • Figure 7B is a graph showing the distribution of CA 125 in normal, to benign, to cancer patients.
  • Figure 8 is a graph showing the concentration of hK6 in pre-surgical and post-surgical serum samples of ovarian cancer patients.
  • Figure 9 is a graph showing the correlation between serum hK6 and CA125 concentrations.
  • Figure 10 is a graph showing the sensitivity and specificity of serum hK6 concentrations.
  • Figure 11 A is a graph showing hK6 concentration versus stage of ovarian cancer.
  • Figure 1 IB is a graph showing hK6 concentration versus grade of ovarian cancer.
  • Figure 12A is a graph showing the survival probability versus progression -free survival (PFS).
  • Figure 12B is a graph showing the survival probability versus overall survival (OS).
  • Figure 13(A) is a graph showing the frequency distribution of hK6 specific activity in ovarian tumor extracts.
  • the value of 35ng/mg of total protein corresponds to the limit that, according to Chi square analysis, gives the best prediction of overall survival of the study population.
  • B Plot of hK6 tumor specific activity versus Chi-square statistic to determine the limit between hK6 positive and hK6 negative tumors that is most predictive of overall survival.
  • FIG 14 is a graph showing a comparison of hK6 concentration in extracts from normal ovarian tissues ("normal"), and ovarian cancer ("cancer"). N indicates the number of specimens in each group. Horizontal bars represent the median hK6 specific activity (ng hK6/mg total extract protein) in each group. The Krustal Wallis test showed that extracted hK6 specific activity was significantly elevated in the ovarian tumor preparations (P ⁇ 0.001).
  • Figure 15 is a graph showing the distribution of hK6 specific activity (ng hK6/mg total protein) in tumor extracts from stage I/II and stage III/IV ovarian cancer patients.
  • N indicates the number of tumors comprising each group.
  • Horizontal bars represent the median value of hK6 tumor specific activity.
  • Figure 16 shows Kaplan-Meier survival curves of the entire patient population under study:effect of hK6 status. Top: progression-free survival (PFS). Bottom: overall survival (OS).
  • the patient number in each group (n) is indicated as is the statistical significance (P value) of the survival difference between hK6 positive and hK6 negative groups.
  • P value the statistical significance of the survival difference between hK6 positive and hK6 negative groups.
  • the adverse effect of hK6 positivity on both time to progression and overall survival was significant.
  • Figure 17 are graphs showing the effect of hK6 status (positive or negative) on progression -free survival (PFS) and on overall survival (OS) among patients with Grade I and II ovarian tumor.
  • the patient number in each group (n) is indicated as is the statistical significance (P value) of the survival difference between hK6 positive and hK6 negative individuals.
  • P value the statistical significance of the survival difference between hK6 positive and hK6 negative individuals.
  • the adverse effect of hK6 positivity both on time to progression and on overall survival was significant (P ⁇ 0.002).
  • Figure 18 is a blot showing immunohistochemical localization of hK6 in ovarian neoplasms of varying malignant potential, cell type, and origin (epithelial versus mesenchymal).
  • A Invasive papillary serous adenocarcinoma, the common malignant epithelial tumor of the ovary. Note strong cytoplasmic staining of many tumor cells, and absence of any staining of stroma or vessels.
  • B Serous cystadenofibroma, a benign, mixed epithelial and fibrous neoplasm. Innumostaining is absent in the fibrous component, but strongly positive in the cytoplasm of the epithelium lining the cysts.
  • the present invention provides a method for monitoring, diagnosing, or for the prognosis of ovarian carcinoma in a subject by detecting hK6 in a biological sample from the subject.
  • the method comprises reacting the sample with an agent that binds to hK6, preferably an antibody specific for hK6 which is directly or indirectly labelled with a detectable substance, and detecting the detectable substance.
  • the methods of the invention may be used for the detection of either an over- or an under- abundance of hK6 relative to a non- disorder state or the presence of a modified (e.g., less than full length) hK6 which correlates with a disorder state (e.g ovarian cancer), or a progression toward a disorder state.
  • the methods described herein may be used to evaluate the probability of the presence of malignant or pre- malignant cells, for example, in a group of cells freshly removed from a host. Such methods can be used to detect tumors, quantitate their growth, and help in the diagnosis and prognosis of disease.
  • the methods can be used to detect the presence of cancer metastasis, as well as confirm the absence or removal of all tumor tissue following surgery, cancer chemotherapy, and/or radiation therapy. They can further be used to monitor cancer chemotherapy and tumor reappearance.
  • the methods of the invention are particularly useful in the diagnosis of late stage ovarian carcinoma and for the prognosis of ovarian carcinoma disease progression and mortality.
  • increased levels of hK6 detected in serum compared to a standard are indicative of late stage disease
  • increased levels of hK6 in tumor tissues or extracts thereof compared to a standard are indicative of increased risk of disease progression and mortality.
  • sample means a material known to or suspected of expressing or containing hK6.
  • the test sample can be used directly as obtained from the source or following a pretreatment to modify the character of the sample.
  • the sample can be derived from any biological source, such as tissues or extracts, including cells (e.g. tumor cells) and physiological fluids, such as, for example, whole blood, plasma, serum, saliva, ocular lens fluid, cerebral spinal fluid, sweat, urine, milk, ascites fluid, synovial fluid, peritoneal fluid and the like.
  • the sample can be obtained from animals, preferably mammals, most preferably humans.
  • the sample can be treated prior to use, such as preparing plasma from blood, diluting viscous fluids, and the like.
  • Methods of treatment can involve filtration, distillation, extraction, concentration, inactivation of interfering components, the addition of reagents, and the like.
  • Proteins may be isolated from the samples and utilized in the methods of the invention.
  • the biological sample is serum or tumor tissue extracts, most preferably serum.
  • the method described herein is adapted for diagnosing and monitoring, and for the prognosis of ovarian carcinoma by detecting hK6 in biological samples from a subject.
  • These applications require that the amount of hK6 detected in a sample from a subject being tested be compared to levels detected for another sample or an earlier sample from the subject, or levels detected for a control sample.
  • Levels for control samples from healthy subjects or subjects with benign disease may be established by prospective and/or retrospective statistical studies. Healthy subjects who have no clinically evident disease or abnormalities may be selected for statistical studies. Diagnosis may be made by a finding of statistically different levels of hK6 compared to a control sample or previous levels detected for the same subject.
  • hK6 refers to human kallikrein 6, (also known as zyme, protease M, and neurosin) a trypsin-like serine protease of 244 amino acids in length, of which 16 amino acids constitute the signal peptide and 5 amino acids, the activation peptide (7, 8, and 9).
  • the term includes all homologs, naturally occurring allelic variants, isoforms and precursors of human kallikrein 6 of GenBank Accession Nos. AF013988, AF149289, HSU62801, D78203, and NM002774.
  • allelic variants of human kallikrein 6 will share significant homology (70-90%) to the sequences shown in GenBank Accession Nos. AF013988, AF149289, HSU62801, D78203, and NM002774. Allelic variants may contain conservative amino acid substitutions from the LK6 sequence or will contain a substitution of an amino acid from a corresponding position in a hK6 homologue such as, for example, the murine kallikrien 6 homologue.
  • subject refers to a warm-blooded animal such as a mammal which is afflicted with or suspected to be afflicted with ovarian cancer. Preferably, "subject” refers to a human.
  • the antibodies specific for hK6 used in the methods of the invention may be obtained from scientific or commercial sources.
  • isolated native hK6 or recombinant hK6 may be utilized to prepare antibodies, monoclonal or polyclonal antibodies, and immunologically active fragments (e.g. a Fab or (Fab) 2 fragment), an antibody heavy chain, an antibody light chain, humanized antibodies, a genetically engineered single chain F v molecule (Ladner et al, U.S. Pat. No. 4,946,778), or a chimeric antibody, for example, an antibody which contains the binding specificity of a murine antibody, but in which the remaining portions are of human origin.
  • Antibodies including monoclonal and polyclonal antibodies, fragments and chimeras, may be prepared using methods known to those skilled in the art.
  • antibodies used in the methods of the invention are reactive against hK6 if they bind with a K a of greater than or equal to 10 "7 M.
  • K a of greater than or equal to 10 "7 M.
  • mouse polyclonal antibodies and rabbit polyclonal antibodies are utilized.
  • Antibodies specifically reactive with hK6, or derivatives, such as enzyme conjugates or labeled derivatives, may be used to detect hK6 in various biological samples, for example they may be used in any known immunoassays which rely on the binding interaction between an antigenic determinant of a protein and the antibodies. Examples of such assays are radioimmunoassays, enzyme immunoassays (e.g.ELISA), immunofluorescence, immunoprecipitation, latex agglutination, hemagglutination, and histochemical tests.
  • An antibody specific for hK6 may be labelled with a detectable substance and localised or identified in biological samples based upon the presence of the detectable substance.
  • detectable substances include, but are not limited to, the following: radioisotopes (e.g., 3 H, 14 C, 35 S, 125 1, 131 I), fluorescent labels
  • luminescent labels such as luminol
  • enzymatic labels e.g., horseradish peroxidase, beta-galactosidase, luciferase, alkaline phosphatase, acetylcholinesterase
  • biotinyl groups which can be detected by marked avidin e.g., streptavidin containing a fluorescent marker or enzymatic activity that can be detected by optical or calorimetric methods
  • predetermined polypeptide epitopes recognized by a secondary reporter e.g., leucine zipper pair sequences, binding sites for secondary antibodies, metal binding domains, epitope tags.
  • Indirect methods may also be employed in which the primary antigen-antibody reaction is amplified by the introduction of a second antibody, having specificity for the antibody reactive against hK6.
  • a second antibody having specificity for the antibody reactive against hK6.
  • the antibody having specificity against hK6 is a rabbit IgG antibody
  • the second antibody may be goat anti-rabbit gamma-globulin labelled with a detectable substance as described herein.
  • Time-resolved fluorometry may be used to detect a signal.
  • the method described in Christopoulos TK and Diamandis EP Anal Chem 1992:64:342-346 may be used with a conventional time- resolved fluorometer.
  • a method wherein a hK6 antibody is labelled with an enzyme, a substrate for the enzyme is added wherein the substrate is selected so that the substrate, or a reaction product of the enzyme and substrate, forms fluorescent complexes with a lanthanide metal.
  • a lanthanide metal is added and hK6 is quantitated in the sample by measuring fluorescence of the fluorescent complexes.
  • the antibodies specific for hK6 may be directly or indirectly labelled with an enzyme. Enzymes are selected based on the ability of a substrate of the enzyme, or a reaction product of the enzyme and substrate, to complex with lanthanide metals such as europium and terbium.
  • suitable enzymes include alkaline phosphatase and ⁇ -galactosidase.
  • the enzyme is alkaline phosphatase.
  • the hK6 antibodies may also be indirectly labelled with an enzyme.
  • the antibodies may be conjugated to one partner of a ligand binding pair, and the enzyme may be coupled to the other partner of the ligand binding pair.
  • Representative examples include avidin-biotin, and riboflavin-riboflavin binding protein.
  • the antibodies are biotinylated, and the enzyme is coupled to streptavidin.
  • antibody bound to hK6 in a sample is detected by adding a substrate for the enzyme.
  • the substrate is selected so that in the presence of a lanthanide metal (e.g. europium, terbium, samarium, and dysprosium, preferably europium and terbium), the substrate, or a reaction product of the enzyme and substrate, forms a fluorescent complex with the lanthanide metal.
  • a lanthanide metal e.g. europium, terbium, samarium, and dysprosium, preferably europium and terbium
  • Examples of enzymes and substrates for enzymes that provide such fluorescent complexes are described in U.S. Patent No. 5,3112,922 to Diamandis.
  • the substrate employed in the method may be 4-methylumbelliferyl phosphate, or 5-fluorosalicyl phosphate.
  • the fluorescence intensity of the complexes is typically measured using a time-resolved fluorometer e.g. a CyberFluor 615 Imunoanalyzer (Nordion International, Kanata, Ontario).
  • the sample, an antibody specific for hK6, or hK6 may be immobilized.
  • suitable carriers are agarose, cellulose, dextran, Sephadex, Sepharose, liposomes, carboxymethyl cellulose polystyrene, filter paper, ion-exchange resin, plastic film, plastic tube, glass beads, polyamine-methyl vinyl- ether-maleic acid copolymer, amino acid copolymer, ethylene-maleic acid copolymer, nylon, silk, etc.
  • the carrier may be in the shape of, for example, a tube, test plate, well, beads, disc, sphere etc.
  • the immobilized antibody may be prepared by reacting the material with a suitable insoluble carrier using known chemical or physical methods, for example, cyanogen bromide coupling.
  • the present invention provides means for determimng hK6 in a blood sample or tumor tissue extract, preferably a serum sample, by measuring hK6 by immunoassay.
  • a blood sample or tumor tissue extract preferably a serum sample
  • immunoassay methods can be used to measure hK6.
  • an hK6 immunoassay method may be competitive or noncompetitive.
  • Competitive methods typically employ an immobilized or immobilizable antibody to hK6 (anti-hK6) and a labeled form of hK6. Sample hK6 and labeled hK6 compete for binding to anti-hK6.
  • the amount of the label in either bound or unbound fraction is measured and may be correlated with the amount of hK6 in the test sample in any conventional manner, e.g., by comparison to a standard curve.
  • a non-competitive method is used for the determination of hK6, with the most common method being the "sandwich” method.
  • two anti-hK6 antibodies are employed.
  • One of the anti- hK6 antibodies is directly or indirectly labeled (sometimes referred to as the "detection antibody”) and the other is immobilized or immobilizable (sometimes referred to as the "capture antibody”).
  • the capture and detection antibodies can be contacted simultaneously or sequentially with the test sample.
  • Sequential methods can be accomplished by incubating the capture antibody with the sample, and adding the detection antibody at a predetermined time thereafter (sometimes referred to as the "forward” method); or the detection antibody can be incubated with the sample first and then the capture antibody added (sometimes referred to as the "reverse” method). After the necessary incubation(s) have occurred, to complete the assay, the capture antibody is separated from the liquid test mixture, and the label is measured in at least a portion of the separated capture antibody phase or the remainder of the liquid test mixture. Generally it is measured in the capture antibody phase since it comprises hK6 bound by ("sandwiched" between) the capture and detection antibodies.
  • the capture and detection antibodies are polyclonal antibodies.
  • the label used in the detection antibody can be selected from any of those known conventionally in the art.
  • the label may be an enzyme or a chemiluminescent moiety, but it can also be a radioactive isotope, a fluorophor, a detectable ligand (e.g., detectable by a secondary binding by a labeled binding partner for the ligand), and the like.
  • the antibody is labelled with an enzyme which is detected by adding a substrate that is selected so that a reaction product of the enzyme and substrate forms fluorescent complexes.
  • the capture antibody is selected so that it provides a means for being separated from the remainder of the test mixture.
  • the capture antibody can be introduced to the assay in an already immobilized or insoluble form, or can be in a immobilizable form, that is, a form which enables immobilization to be accomplished subsequent to introduction of the capture antibody to the assay.
  • An immobilized capture antibody may comprise an antibody covalentiy or noncovalently attached to a solid phase such as a magnetic particle, a latex particle, a microtiter plate well, a bead, a cuvette, or other reaction vessel.
  • an immobilizable capture antibody is antibody which has been chemically modified with a ligand moiety, e.g., a hapten, biotin, or the like, and which can be subsequently immobilized by contact with an immobilized form of a binding partner for the ligand, e.g., an antibody, avidin, or the like.
  • the capture antibody may be immobilized using a species specific antibody for the capture antibody that is bound to the solid phase.
  • a particular sandwich immunoassay method of the invention employs two antibodies reactive against hK6, a second antibody having specificity against an antibody reactive against hK6 labelled with an enzymatic label, and a fluorogenic substrate for the enzyme.
  • the enzyme is alkaline phosphatase (ALP) and the substrate is 5-fluorosalicyl phosphate.
  • ALP cleaves phosphate out of the fluorogenic substrate, 5-fluorosalicyl phosphate, to produce 5-fluorosalicylic acid (FSA).
  • 5-Fluorosalicylic acid can then form a highly fluorescent ternary complex of the form FSA-Tb(3+)-EDTA, which can be quantified by measuring the Tb3+ fluorescence in a time-resolved mode. Fluorescence intensity is measured using a time-resolved fluorometer as described herein.
  • immunoassay methods and formats are intended to be exemplary and are not limiting since, in general, it will be understood that any immunoassay method or format can be used in the present invention.
  • kits for quantitating hK6 in a sample may contain antibodies specific for hK6, antibodies against the antibodies labelled with an enzyme; and a substrate for the enzyme.
  • the kit may also contain microtiter plate wells, standards, assay diluent, wash buffer, adhesive plate covers, and/or instructions for carrying out a method of the invention using the kit.
  • Antibodies specific for hK6 may also be used in imaging methodologies in the management of ovarian cancer.
  • the invention provides a method for imaging tumors associated with hK6 and optionally one or more other kallikreins, preferably kallikreins associated with ovarian cancer, including but not limited to hK4, hK5, hK8, hK9, hKlO and hKll.
  • the invention also contemplates imaging methods described herein using multiple markers for ovarian cancer.
  • a method for imaging ovarian cancer may utilize an agent that binds to hK6 and one or more of an agent that binds to human stratum corneum chymotryptic enzyme (HSCCE), kallikrein 4, kallikrein 5, kallikrein 8, kallikrein 9, kallikrein 10, kallikrein 11, CA125, CA15-3, CA19-9, OVX1, lysophosphatidic acid (LPA) or carcinoembryonic antigen (CEA), preferably Ca 125.
  • HSCCE human stratum corneum chymotryptic enzyme
  • kallikrein 4 kallikrein 5, kallikrein 8, kallikrein 9, kallikrein 10, kallikrein 11, CA125, CA15-3, CA19-9, OVX1, lysophosphatidic acid (LPA) or carcinoembryonic antigen (CEA), preferably Ca 125.
  • LSA lysophosphatidic acid
  • CEA carcino
  • the method is an in vivo method and a subject or patient is administered one or more agents that carry an imaging label and that are capable of targeting or binding to a kallikrein, preferably hK6.
  • the agent is allowed to incubate in vivo and bind to the kallikrein(s) associated with a tumor, preferably ovarian tumors.
  • the presence of the label is localized to the ovarian cancer, and the localized label is detected using imaging devices known to those skilled in the art.
  • the agent may be an antibody or chemical entity which recognizes the kallikrein(s).
  • the agent is a polyclonal antibody or monoclonal antibody, or fragments thereof, or constructs thereof including but not limited to, single chain antibodies, bifunctional antibodies, molecular recognition units, and peptides or entities that mimic peptides.
  • the antibodies specific for the kallikreins used in the methods of the invention may be obtained from scientific or commercial sources, or isolated native kallikrein or recombinant kallikrein may be utilized to prepare antibodies etc as described herein.
  • An agent may be a peptide that mimics the epitope for an antibody specific for a kallikrein and binds to the kallikrein.
  • the peptide may be produced on a commercial synthesizer using conventional solid phase chemistry.
  • a peptide may be prepared that includes either tyrosine lysine, or phenylalanine to which N 2 S 2 chelate is complexed (See U.S. Patent No. 4,897,255).
  • the anti-kallikrein peptide conjugate is then combined with a radiolabel (e.g. sodium 99m Tc pertechnetate or sodium IS8 Re perrhenate) and it may be used to locate a kallilkrein producing tumor.
  • a radiolabel e.g. sodium 99m Tc pertechnetate or sodium IS8 Re perrhenate
  • the agent carries a label to image the kallikreins.
  • the agent may be labelled for use in radionuclide imaging.
  • the agent may be directly or indirectly labelled with a radioisotope.
  • radioisotopes that may be used in the present invention are the following: Ac, At, Ba, Ba, Be, Bi,
  • the radioisotope is I31 1, 125 I, I23 I, ⁇ I, 99m Tc, 90 Y, 186 Re, 188 Re, 3 P, 153 Sm, 67 Ga, 201 T1 77 Br, or 18 F, and is imaged with a photoscanning device.
  • Procedures for labeling biological agents with the radioactive isotopes are generally known in the art.
  • U.S. Pat. No. 4,302,438 describes tritium labeling procedures.
  • Procedures for iodinating, tritium labeling, and 35 S labeling especially adapted for murine monoclonal antibodies are described by Goding, J. W. (supra, pp 124-126) and the references cited therein.
  • An agent may also be labeled with a paramagnetic isotope for purposes of an in vivo method of the invention.
  • elements that are useful in magnetic resonance imaging include gadolinium, terbium, tin, iron, or isotopes thereof. (See, for example, Schaefer et al., (1989) JACC 14, 472-480; Shreve et al., (1986) Magn. Reson. Med. 3, 336-340; Wolf, G L., (1984) Physiol. Chem. Phys. Med. NMR 16, 93-95; Wesbey et al., (1984) Physiol. Chem. Phys. Med.
  • the agent may be administered to the patient, it is localized to the tumor having a kallikrein with which the agent binds, and is detected or "imaged" in vivo using known techniques such as radionuclear scanning using e.g., a gamma camera or emission tomography.
  • known techniques such as radionuclear scanning using e.g., a gamma camera or emission tomography.
  • a positron emission transaxial tomography scanner such as the scanner designated Pet VI located at Brookhaven National Laboratory, can also be used where the radiolabel emits positrons (e.g., ⁇ C, I8 F, 15 O, and 13 N).
  • Whole body imaging techniques using radioisotope labeled agents can be used for locating both primary tumors and tumors which have metastasized.
  • Antibodies specific for kallikreins, or fragments thereof having the same epitope specificity are bound to a suitable radioisotope, or a combination thereof, and administered parenterally.
  • administration preferably is intravenous.
  • the bio-distribution of the label can be monitored by scintigraphy, and accumulations of the label are related to the presence of ovarian cancer cells.
  • Whole body imaging techniques are described in U.S. Pat. Nos. 4,036,945 and 4,311,688.
  • agents useful for diagnosis and therapeutic use which can be coupled to antibodies and antibody fragments include metallothionein and fragments (see, U.S. Pat. No. 4,732,864). These agents are useful in diagnosis staging and visualization of cancer, in particular ovarian cancer, so that surgical and/or radiation treatment protocols can be used more efficiently.
  • kits for carrying out the methods of the invention.
  • the kits include an antibody or an antibody fragment which binds specifically to an epitope of a kallikrein, and means for detecting binding of the antibody to its epitope associated with tumor cells, either as concentrates (including lyophilized compositions), which may be further diluted prior to use or at the concentration of use, where the vials may include one or more dosages.
  • concentrates including lyophilized compositions
  • the vials may include one or more dosages.
  • single dosages may be provided in sterilized containers, having the desired amount and concentration of agents.
  • Containers that provide a formulation for direct use usually do not require other reagents, as for example, where the kit contains a radiolabelled antibody preparation for in vivo imaging.
  • the following non-limiting examples are illustrative of the present invention:
  • Diflunisal phosphate (DEP) was synthesized in the laboratory (diflunisal, obtained from Sigma Chemical Co., St. Louis, MO). The stock solution of DFP was 0.01 mol/L in 0.1 mol/L NaOH. DEP stock solutions are stable at 4°C for at least 6 months. Alkaline phosphatase-labeled goat anti-rabbit IgG (GARIg-)
  • ALP sheep anti-mouse immunoglobulin G
  • GARIg-ALP sheep anti-mouse immunoglobulin G (Fc fragment-specific) were obtained from Jackson Immunoresearch, West Grove, PA.
  • Working solutions of GARIg-ALP were prepared by diluting the stock solution 3,000-fold in the assay buffer (described below).
  • White, opaque 12-well polystyrene microtiter strips were obtained from Dynatech Labs., Alexandria, VA.
  • the substrate buffer was a Tris buffer (0.1 mol/L, pH 9.1) containing 0.1 mol of NaCl and 1 mmol of MgCl 2 per liter.
  • the substrate working solution (DFP, 1 mmol/L in substrate buffer) was prepared just before use by diluting the DFP stock solution 10-fold in the substrate buffer.
  • the wash solution was prepared by dissolving 9 g of NaCl and 0.5 g of polyoxyethylenesorbitan monolaurate (Tween 20) in 1 L of a 10 mmol/L Tris buffer, pH 7.40.
  • the developing solution contained 1 mol of Tris base, 0.4 mol of NaOH, 2 mmol of TbCl 3 and 3 mmol of EDTA per liter (no pH adjustment).
  • the assay buffer A was a 50 mmol/L Tris buffer, pH 7.40, containing 60 g of BSA, 0.5 g of sodium azide, 100 mL of normal goat serum, 25 mL of normal mouse serum, 5 g of bovine IgG and 0.5 g of Tween 20 per liter.
  • the assay buffer B was the same as assay buffer A except that mouse serum was omitted.
  • hK6 Several clinical samples were used to examine the presence of hK6. These included serum and urine samples from male and female individuals (healthy blood donors), breast cyst fluids obtained by needle aspiration, breast tumor cytosolic extracts, prepared as described previously (11), amniotic fluids, milks from lactating women, seminal plasmas, nipple aspirate fluids (NAFs) and cerebrospinal fluids (CSFs). In addition, a panel of human tissue cytosolic extracts, prepared as previously described were tested (Hassapoglidou, S. et al Oncogene 1993, 8:1501-1509.). To establish optimal measuring conditions, all samples were tested at various dilutions. The procedures are in accordance with the ethical standards of the Helsinki Declaration of 1975, as revised in 1983.
  • hK6 protein Production and purification of recombinant hK6 protein.
  • Human 293 cells transfected with a plasmid containing the 1.4-kb hK6 cDNA were subjected to selection by growth in G418 (400 mg/L) for three weeks, after which time stable transformants were isolated.
  • G418 400 mg/L
  • One clone generated identifiable amounts of hK6 protein in the culture medium. This cell line was cultured and the tissue culture supernatant was collected and concentrated by using Centricon ultrafiltration devices (Millipore, Waltham, MA 02454).
  • hK6 Purification of hK6 from the concentrated cell culture supematants was achieved by reversed-phase high pressure liquid chromatography (C-8, Aquapore RP-300, 0.45 x 25 cm, Applied Biosystems, Foster City, CA) using a linear gradient of 0.1% trifluoroacetic acid/acetonitrile. Generally, the gradient increased at a rate of 1% acetonitrile per min.
  • Factions containing hK6 were located by SDS-polyacrylamide gel electrophoresis, collected, lyophylized and stored at -20°C (Little SP et al, J. Bil Chem 1997:272:251135-25142). Development of polyclonal antibodies against hK6.
  • hK6 protein Purified recombinant hK6 protein was used to immunize rabbits and mice using standard procedures (Campbell Am, Production and purification of antibodies. In: Immunoassay. Diamandis EP Christopoulos TK (eds)00. 95-115, Academic Press, San Diego, 1996). The rabbit and mice antisera were used for the development of the immunofluorometric assay without further purification.
  • hK6 calibrators of 0, 1, 5, 20, 50 and 200 ⁇ g/L were prepared by diluting recombinant purified hK6 protein in a 50 mmol/L Tris buffer, pH 7.80, containing 60 g of BSA and 0.5 g of sodium azide per liter. hK6 assay. Calibrators or samples (100 ⁇ L) were pipetted into the microtiter wells and 50 ⁇ L of the polyclonal mouse anti-hK6 antiserum, diluted 5,000-fold in assay buffer B, were added. The wells were then incubated with shaking at room temperature for 2 hours and washed six times.
  • HPLC High performance liquid chromatography
  • a typical calibration curve of the proposed hK6 assay is shown in Figure 1.
  • the detection limit defined as the concentration of hK6 corresponding to the fluorescence of the zero calibrator plus two standard deviations, is ⁇ 0.5 ⁇ g/L.
  • Within-run and between-run precision was assessed at various hK6 concentrations between 2-50 ⁇ g/L and with various clinical samples. In all cases, the coefficients of variation (CVs) were between 2 and 9%, consistent with the precision of typical microtiter plate-based immunoassays.
  • SPECIFICITY hK6 protein was detected in various biological fluids.
  • hK6 was also detected in male and female serum samples, in the majority of seminal plasmas and in a relatively small percentage of amniotic fluids and breast tumor cytosolic extracts. hK6 protein was not detected in urine.
  • the present inventors have developed polyclonal antibodies and an immunofluorometric procedure suitable for quantifying hK6 protein in biological fluids and tissue extracts. Since a rich natural source of hK6 protein is not known, recombinant hK6 protein was used for the development of polyclonal rabbit and mice antibodies. This recombinant protein ensures high purity without any contaminating proteins.
  • the chosen assay configuration does not need any further purification or conjugation of the primary antibodies used, and it is thus a convenient method for developing sensitive immunofluorometric procedures. The same principle has been adopted previously for measuring the p53 tumor suppressor in biological fluids (Hassapoglidou S et al, Oncogene 1993: 8: 1501-1509).
  • the developed immunoassay for hK6 protein demonstrates good sensitivity, dynamic range and linearity ( Figure 1). It has been further verified that this assay detects a single immunoreactive band in the biological fluids examined. In serum, this proteinase is present in its free form, similarly to observations with hK2 measurements (Black, MH et al Clin Chem 1999; 45:790-799). However, this is in contrast to the situation with PSA, which is known to be present in serum mainly bound to i-antichymotrypsin (Stenman U-H, et al, Cancer Res. 1991: 51:222-226); Christensson A et al Cur J Biochem 1990; 194; 755-763).
  • hK6 protein Large amounts of hK6 protein were detected in cerebrospinal fluid, which are consistent with the observation that hK6 is expressed at high levels in brain tissue (Little, supra). hK6 was also found in male and female sera and seminal plasmas and in a small percentage of amniotic fluids and breast tumor cytosols.
  • the assay developed here represents the first method for detecting hK6 protein in biological fluids.
  • the results further demonstrate that hK6 is a secreted protein, as predicted by its deduced amino acid sequence (Yousek GM et al Genomics 1999;62:251-259).
  • the details of this immunofluorometric assay have been described (See Example 1 and ref. 12).
  • the assay utilizes two hK6-specific polyclonal antibodies, one raised in mouse and the other raised in rabbit. This is a non-competitive immunofluorometric procedure which incorporates the principles of time-resolved fluorometry for detection.
  • the assay measures hK6 in the range of 0.5-200 ⁇ g/L with precision ⁇ 10%. Serum samples were analyzed without sample pretreatment. Clinical samples
  • CA15.3, CA19.9 and hCG were analyzed on the Immuno 1 immunoassay analyzer (Bayer Diagnostics, Tarrytown, NY) and calcitonin was measured with a radioimmunoassay kit from Diasorin, Italy.
  • the upper limit of normal values for the tumor markers were 35 KU/L (CA125), 4 ⁇ g/L (PSA), 10 ⁇ g/L (AFP), 5 ⁇ g/L (CEA), 35 KU/L (CA15.3), 37 KU/L (CA19.9), 10 IU/L (hCG) and 100 ng/L (calcitonin).
  • the data of Table 2 summarize the findings and demonstrate that among all cancer types tested (normal males and females versus breast, thyroid, testicular, gastrointestinal, prostate, lung and ovarian cancer), only ovarian cancer patients show significantly elevated levels of this biomarker in the circulation. Approximately 66% of patients had levels higher than 15 ⁇ g/L, a cutoff that affords 98-100% specificity for all other cancers tested. Although these data are highly promising, regarding value of hK6 as a circulating biomarker for ovarian carcinoma, it should be taken into consideration that all patients with ovarian cancer had relatively high levels of CA125 (> 372 KU/L, which is approximately 10 times higher than the upper reference range). The data of Figure 6 indicate that serum levels of hK6 change with time during ovarian cancer monitoring, suggesting that this biomarker may be useful for monitoring patients after primary treatment.
  • hK6 represents a novel serum biomarker for ovarian cancer which may be useful for disease diagnosis and monitoring.
  • the characteristics of the ovarian cancer patients in terms of stage, grade, histotype, residual tumor post-surgery, debulking success and response to chemotherapy are shown in Table 7.
  • Serum samples from all patients were collected pre-surgically, before initiation of therapy, and stored at -80°C until analysis.
  • serum was also available post-surgery. This sample was obtained approximately 2-3 weeks post-surgery.
  • the concentration of hK6 was measured with a procedure described herein (12) with some modifications.
  • This assay employs a monoclonal anti-hK6 mouse antibody, coated directly on microtiter wells (capture antibody), a polyclonal rabbit detection antibody and an alkaline phosphatase-conjugated goat anti-rabbit antibody. Signal was quantified by time-resolved fluorometry.
  • the assay has a detection limit of 0.1 ⁇ gL and a dynamic range up to 50 ⁇ g L. Precision was ⁇ 10% within the measurement range.
  • the serum samples were analyzed in duplicate with inclusion of three quality control samples in every run. Statistical analysis
  • Receiver operating characteristic (ROC) curves were constructed for hK6 and CA125 serum concentration by plotting sensitivity versus (1 -specificity) and the areas under the ROC curves (AUC) were calculated.
  • the non-cancer group included the normal individuals and the patients with benign disease. Correlations between different variables were assessed by the Spearman correlation coefficient.
  • the non- parametric Mann- Whitney U test was used to determine differences between two groups and the non- parametric Kruskal-Wallis test was used for the analysis of differences among more than two groups. These tests treated hK6 concentration in serum as a continuous variable.
  • hK6 serum concentration was also classified as either hK6- ⁇ ositive (> 4.4 ⁇ g/L) or hK6-negative ( ⁇ 4.4 ⁇ g/L).
  • the relationship of this dichotomous variable with other clinicopathological correlates was established with the Chi Square ( ⁇ 2 ) test or the Fisher's Exact test, as appropriate.
  • Kaplan-Meier progression-free survival and overall survival curves were constructed to demonstrate the survival differences between the hK6-positive and hK6-negative patients.
  • the log rank test was used to examine the significance of the differences among the survival curves.
  • the impact of serum hK6 concentration on patient overall survival (OS) and on progression of the disease (progression-free survival; PFS) was assessed with the hazards ratio, calculated by both univariate and multivariate Cox proportional hazards regression models.
  • OS patient overall survival
  • PFS progression-free survival
  • the hazards ratio calculated by both univariate and multivariate Cox proportional hazards regression models.
  • the clinical and pathological variables that may affect survival including stage of disease, tumor grade, residual tumor and histologic type were adjusted.
  • pre-surgical serum hK6 concentration is not different between normal and benign disease patients but is significantly elevated in a proportion of ovarian cancer patients ( Figure 7A). Conversely, CA125 values are progressively increased from normal, to benign, to cancer patients ( Figure 7B). For dichotomous classification of this patient population as hK6-positive and hK6-negative, the hK6 cutoffs of 4.2 ⁇ g/L (90% diagnostic specificity) and 4.4 ⁇ g/L (95% diagnostic specificity) were selected. Changes of serum hK6 concentration post-surgery: For 105 patients with ovarian cancer, pre-surgical and post-surgical serum samples were selected.
  • hK6 concentration ranges from 2-40 ⁇ g/L while samples with hK6 levels around 6 ⁇ g/L may have CA125 values ranging from 5 to > 5,000 KU/L.
  • Diagnostic sensitivity and specificitv of serum hK6 concentration For this calculation, the various subgroups of patients were considered, as shown in Table 4. In the non-cancer group, all patients who are either normal or have benign disease were included. When the whole patient group was analyzed, diagnostic sensitivity is around 54% at 90% specificity and 50% at 95% specificity.
  • the receiver operating characteristic (ROC) curve of Figure 10 indicates a slight diagnostic advantage of CA125, in comparison to hK6.
  • the two markers can work in combination, since hK6 concentration could be elevated in a subset of patients with relatively low CA125.
  • the diagnostic sensitivity of hK6 is 71 and 65% at specificities of 90 and 95%, respectively.
  • the subgroup of patients with low CA125 ⁇ 23 KU/L
  • about 13-17% of patients will still have elevated hK6, at hK6 cut-offs of 4.4 (95% specificity) or 4.3 ⁇ g/L (90% specificity), respectively.
  • the diagnostic sensitivity of hK6 is 15-26% at specificities of 95-90%, respectively (Table 4).
  • Table 6 summarizes the relative risk (RR) of having ovarian cancer, based on serum hK6 concentration.
  • the relative risk increases exponentially with increasing hK6 concentration, reaching a value of 20 when hK6 is > 4.3 ⁇ g/L.
  • Prognostic value of serum hK6 Higher ovarian cancer stage and grade are strongly associated with higher serum hK6 concentration ( Figure 11 and Table 7). Furthermore, serous adenocarcinomas are more frequently associated with high serum hK6 concentration (positivity 68%) followed by endometrioid tumors (positivity 33%); mucinous tumors are rarely associated with high serum hK6 (9%). Furthermore, high serum hK6 concentration is associated with presence of residual tumor, suboptimal debulking and poor response to chemotherapy. All these associations were highly significant (p ⁇ 0.001).
  • CA125 The traditional ovarian cancer biomarker, CA125, falls short of being able to diagnose early ovarian cancer. In addition to its low sensitivity for early disease, CA125 also suffers from low specificity i.e. elevated levels are seen in many benign abdominal diseases. Currently, it is widely accepted that no single cancer biomarker will provide all the necessary information for optimal cancer diagnosis and management. The current trend is to focus on the identification of multiple biomarkers which can be used in combination. Such approaches have already shown to have clinical potential in ovarian cancer (28,29).
  • Serum hK6 represents a novel biomarker for ovarian carcinoma. This biomarker is more specific for ovarian cancer than CA125 since, in contrast to CA125, elevations were not seen in benign diseases (Figure 7).
  • the diagnostic sensitivity of hK6 is slightly less than the diagnostic sensitivity of CA125 at the same specificity cut-offs (Table 5 and Figure 10). However, hK6 can increase the diagnostic sensitivity of
  • CA125 at all stages of the disease including stage I/II disease (Table 5).
  • stage I/II disease Despite the weak correlation between hK6 and CA125 ( Figure 9), there are still patients with normal CA125 who have elevated hK6 levels (Table 4).
  • CA125 and hK6 could be used in combination to increase the diagnostic sensitivity of each of the biomarkers alone.
  • hK6 concentration is more frequently elevated in serous ovarian carcinoma than in endometrioid and mucinous carcinomas (Table 7). Serum hK6 concentration is also more frequently elevated in late stage and higher grade disease. Serum hK6 concentration is a powerful predictor of patient outcomes.
  • Serum hK6 concentration is a more powerful prognostic indicator that serum CA125.
  • the prognostic value of CA125 disappears in multivariate analysis while serum hK6 is an independent prognostic indicator, as shown in the multivariate analysis of Table 8.
  • Serum hK6 likely originates from tumor cells, since post-operatively, the levels are significantly decreased (Figure 8).
  • proteolytic enzymes have prognostic value in many cancers (for reviews, see 45 and 46).
  • the biological mechanisms of proteolytic enzyme involvement in cancer prognosis includes their ability to degrade extracellular matrix, thus facilitating invasion and metastasis (47-49). It seems likely that multiple members of the human kallikrein gene family are disregulated in ovarian cancer. It is thus possible that other members of this protease family may emerge as potential ovarian cancer biomarkers. If these proteases are involved in cancer progression, they may be suitable candidates as therapeutic targets.
  • Table 7 shows preliminarily that pre-surgical serum hK6 concentration may be a predictor of response to chemotherapy in ovarian cancer patients.
  • 81% had elevated pre- surgical hK6 concentration while 19% of these patients had low hK6 concentration.
  • 57% had low pre-operative hK6 concentration (p ⁇ 0.001).
  • serum hK6 concentration represents a novel biomarker for ovarian carcinoma, which has potential utility as a diagnostic, prognostic and predictive tool.
  • the combination of hK6 and CA125 improves the diagnostic sensitivity of ovarian cancer at all stages, including early stage disease.
  • KLK6 Ovarian Tissue PATIENTS AND METHODS Ovarian Cancer Patients One hundred eighty patients with primary ovarian cancer were included in this study. These patients underwent surgery for ovarian cancer at the Department of Gynecology, University of Turin, Italy. Patient age ranged from 25 to 82 years with a median of 59 years. Clinical and pathological information documented at the time of surgery included clinical stage of the cancer, grade and histology of the tumor, and amount of remaining tumor. Menopausal status was documented and response to chemotherapy monitored. Tumors were staged according to the International Federation of Gynaecology and
  • FIGO Obstetrics
  • Histologic classification was based on the World Health Organization and FIGO recommendations.
  • 80 were classified as serous papillary, 32 as undifferentiated, 27 as endometrioid, 13 as mucinous, 14 as clear cell, 10 as mullerian and 4 as other.
  • the size of the residual tumors ranged from 0 to 9 cm, with a median of 1.1 cm.
  • Patients were monitored for survival and disease progression (no apparent progression or progression) for a median duration of 62 months (range 1-99 months).
  • follow-up information was available for 165 of the patients. 97 (54%) of these relapsed and 61 (34%) died during the course of the follow-up period.
  • Tumor tissue was frozen in liquid nitrogen immediately after surgery and stored at -80°C until extraction.
  • Protein concentration of the extract was determined with the bicinchoninic acid method, with albumin as standard (Pierce Chemical Co., Rockford, IL). Measurement of hK6 in Ovarian Cell Extracts. The concentration of hK6 in tumor cell extract was quantified with a highly sensitive and specific non-competitive immunoassay for hK6 that has been previously described and evaluated in detail (12). The assay incorporated two hK6-specific polyclonal antibodies, one raised in mouse and the other in rabbit, in a sequential two site immunometric format with time resolved fluorescence detection. Analysis of standards, tumor cell extracts and control pools was carried out in duplicate in 96-well polystyrene microtiter plates with 200 ⁇ L of specimen added to the immunoassay.
  • the standard curve using recombinant hK6 protein ranged from 0.5 ⁇ g/L to 200 ⁇ g/L. Assay precision was better than 10%. Signal detection and data reduction were performed automatically by the CyberFluor 615 Immunoanalyzer.
  • hK6 Localization of hK6 in Ovarian Tumor Specimens by Immunohistochemistry.
  • a rabbit polyclonal antibody was raised against hK6 full-size recombinant protein, produced in yeast cells.
  • Immunohistochemical staining for hK6 was performed according to a standard immunoperoxidase method. Briefly, paraffin-embedded tissue sections (4 ⁇ m) were fixed and dewaxed. Endogenous peroxidase activity was blocked with 3% aqueous hydrogen peroxide for 15 minutes. Sections were then treated with 0.4% pepsin at pH 2.0 for 5 minutes at 42°C and blocked with 20% protein blocker (Signet Labs) for 10 minutes.
  • hK6 specific activity in the ovarian tumor extracts was not Gaussian, the non-parametric Mann-Whitney U test was used to determine differences between two groups and the non-parametric Kruskal-Wallis test was used for the analysis of differences among more than two groups. These tests treated hK6 specific activity in the tumor extract (ng hK6/mg total protein) as a continuous variable. hK6 tumor extract specific activity was also classified as either hK6-positive (> 35 ng/mg total protein; see Figure 7B for explanation) or hK6-negative ( ⁇ 35 ng/mg total protein). The relationship of this dichotomous variable to other clinicopathological correlates was established with the Chi Square ( ⁇ 2 ) test or the Fisher's Exact Test, as appropriate.
  • hK6 specific activity in tumor extracts was treated both as a continuous variable and as a dichotomous variable ( ⁇ 35 ng/mg total protein, > 35 ng/mg total protein) in the analyses that follow.
  • hK6 specific activity (ng hK6/mg total protein) was significantly elevated (P ⁇ 0.001 by the Kruskal Wallis test) in extracts of ovarian tumor (mean 32.7, standard error 3.8, range 0.04 to 497) compared to extracts prepared from normal ovarian tissues (mean 3.5, standard error 2.5, range 0.05 to 20.8) or from ovarian tissue with benign disease (mean 3.2, standard error 2.6, range 0.03 to 21.5) (Figure 14).
  • hK6-positive patients were more likely to have advanced disease (stage II-IV), serous tumor histology and greater residual tumor (>1 cm) (all P ⁇ 0.05).
  • hK6 tumor extract specific activity when treated as a continuous variable also associated proportionally with stage of the disease.
  • hK6 status had no such effect among patients with Grade III tumor, nor could any discernible effect be demonstrated among patients with early stage disease and among those with greater than 1 cm of tumor remaining following surgery.
  • Univariate analysis revealed a 2-fold increase in risk of disease progression and of death in the subgroup of patients with advanced disease (stage IE and IV) who were hK6 positive, but the effect was lost in the multivariate analysis. The opposite occurred in the subset of patients characterized by optimal debulking of the tumor at the time of surgery (remaining tumor less than 1 cm in diameter).
  • hK6 positivity had no demonstrable adverse effect on disease progression or on survival by univariate analysis, but did become statistically significant, giving a 3.5 and 5.5-fold increase in adverse risk, respectively, when the data were subjected to multivariate analysis.
  • the emergence of effects in the multivariate model when none are generated by the univariate model happens when the adjusted variables have no impact at all on the outcome. In the case here, this means that stage of disease, tumor grade, tumor histology and patient age had no prognostic potential on disease progression and overall survival in this particular subset of patients. Kaplan- Meier survival curves of the subset of patients with grade I or II ovarian tumor are shown in Figure 17. As expected from the univariate analysis mentioned earlier, there was a significant difference in disease progression and survival between hK6 positive and hK6 negative patients.
  • hK6 positivity across the entire patient population under study was associated with about a 2-fold increase in the risk of both disease progression and of death. This effect was lost when outcomes were adjusted for the other clinicopathological variables and age in multivariate analysis of the entire patient population, but not when the multivariate analysis was restricted to those patients with lower grade tumor and with less residual tumor remaining after surgery ( ⁇ 1 cm in diameter).
  • hK6 positivity predicted about a 4-fold increase in the risk of disease progression and of death (P ⁇ 0.03) while corresponding hazard ratios in the latter subgroup were 3.75 and 5.5, respectively (P ⁇ 0.02).
  • the data show that hK6 positivity has independent predictive potential in these two subgroups and gives insight into tumor behavior over time that cannot be gleaned from the clinical parameters and pathological correlates conventionally measured. Hence hK6 testing could contribute to more individualized effective treatment of such patients.
  • hK6 was found to be frequently overexpressed in ovarian tumors compared to nonmalignant ovarian tissue. This overexpression tended to be higher in tumors from late stage disease than from early stage disease.
  • hK6 is synthesized by the epithelial cells of the ovary and is distributed diffusely within the cytoplasmic compartment.
  • Epithelial ovarian cancer has one of the worst prognoses among gynecologic malignancies, largely because over three-quarters of the diagnoses are made at a time when the disease has already established regional or distant metastases (33).
  • Compounding the problem, tumor progression and aggressiveness correlate variably with conventional clinical and pathological markers.
  • CA 1 .9 levels > 629 KU L (upper ref. range 37 KU L) and CEA levels > 1.000 ⁇ g/L (upper ref. range 5 ⁇ g/L).
  • hK6 ⁇ g/L
  • 2.94 ⁇ 0.099 0.89-6.58 1.49 2.28 2.90 3.54 4.44
  • Table 5 Diagnostic sensitivities for ovarian cancer with CA125 alone, hK6 alone and CA125 + hK6 analysis at 90 and 95% specificity cut-offs for both markers
  • CTX chemotherapy; NC, no change; PD, progressive disease; CR, complete response; PR, partial response; NE, not evaluated
  • Residual tumor (ordinal) 1.09 0.42-2.26 0.15 1.01 0.80-1.24 0.98
  • Table 9 Relationship between hK6 status and other variables in 180 ovarian cancer patients.
  • Histologic type 0.83 0.68-1.00 0.055 0.88 0.69-1.13 0.34
  • Multivariate models were adjusted for stage of disease, residual tumor, histologic type and age.
  • d Multivariate models were adjusted for tumor grade, residual tumor, histologic type and age.
  • f Multivariate models were adjusted for stage of disease, tumor grade, histologic type and age.
  • Diamandis EP Yousef GM, Luo LY, Magklara A, Obiezu CV. The new human kallikrein gene family: implications in carcinogenesis. Trends Endocrinol Metab 2000; 11:54-60. 2. Diamandis EP. Prostate specific antigen - its usefulness in clinical medicine. Trends Endocrinol

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